Moral Distress Among Medical Students: A Systematic Review of Its Causes, Impact and Response

Introduction Moral distress occurs when an individual who is aware of the appropriate moral and ethical course of action is unable to perform it. Medical students are likely to be at increased risk of moral distress. I systematically reviewed the literature to determine the etiology of moral distress among medical students, its impact and response. Methods I searched 9 databases using an identical search strategy for each. Eligible studies had to 1) represent an original, published study; 2) present data about the causes, impact or response to moral distress; 3) measure and report outcomes for medical students; and 4) report findings in English. Following title, abstract and full text review, those articles that did not meet all inclusion criteria were excluded. I searched the reference sections of included studies and relevant review articles for additional manuscripts. Results The search yielded 92 articles. Following title, abstract and full text review, 9 articles were included in the systematic review. Three studies found inconsistency in the relationship between gender and moral distress. One study found empathy was more common in those essays that described moral distress. Studies revealed myriad situations with the potential to cause or contribute to moral distress among medical students, including end of life care, futile care, and inadequate access to care. Situations related to the clinical learning environment also cause or contribute to moral distress. One author found that empathy and metonymy were more common in writing that expressed moral distress. Another found medical students became habituated to situations that could be justified for their learning, though increasingly distressed with exposure to situations that could not. One author found students reported considering dropping out of medical school or choosing a non-clinical specialty due to moral distress. One study found 84% of medical students did not feel medical school had prepared them well to handle moral distress. Discussion and Conclusions Instruments should be developed to measure the presence and severity of moral distress independent of the situation(s) that resulted in it. Eliminating experiences related to the clinical learning environment that are associated with medical student moral distress should be a goal for all schools.